1388

LAWS OF MARYLAND

[Ch. 276

CLASSIFICATIONS FOR THE PURPOSES OF ESTABLISHING CONTRACT
RATES NOR DOES IT PROHIBIT EXPERIENCE RATING;

(6)    THE ORGANIZATION FURNISHES EVIDENCE OF
ADEQUATE INSURANCE COVERAGE OR AN ADEQUATE PLAN FOR
SELF-INSURANCE TO RESPOND TO CLAIMS FOR INJURIES ARISING
OUT OF THE FURNISHING OF HEALTH CARE;

(7)    THE ORGANIZATION HAS PROVIDED, THROUGH
CONTRACT OR OTHERWISE, FOR PERIODIC EXTERNAL AUDIT AND
REVIEW OF ITS HEALTH AND MEDICAL FACILITIES AND SERVICES
IN THE MANNER DETERMINED OR APPROVED BY THE DEPARTMENT OF
HEALTH AND MENTAL HYGIENE, USING METHODS WHICH WILL
PROVIDE MAXIMUM CONFIDENTIALITY AS TO PATIENT IDENTITY
AND ASSURE OBJECTIVE EVALUATION. HOWEVER, THE
ORGANIZATION MAY EMPLOY IN LIEU OF AN EXTERNAL AUDIT ITS
OWN INTERNAL QUALITY OF CARE COMMITTEE AUDIT PROCEDURES,
IF THE PROCEDURES ARE APPROVED BY THE DEPARTMENT OF
HEALTH AND MENTAL HYGIENE. WHERE THERE IS A PROFESSIONAL
STANDARDS REVIEW ORGANIZATION AS DESCRIBED IN 42 U.S.C.
§1320C-1 (SUPP. III 1972), AS AMENDED FROM TIME TO TIME,
WHICH IS CERTIFIED BY THE UNITED STATES DEPARTMENT OF
HEALTH, EDUCATION AND WELFARE AS CAPABLE OF SERVING
PERSONS IN THE AREA IN WHICH THE HEALTH MAINTENANCE
ORGANIZATION IS LOCATED WHO ARE RECEIVING BENEFITS UNDER
"SUBCHAPTER XVIII. - HEALTH INSURANCE FOR THE AGED AND
DISABLED" (MEDICARE) 42 U.S.C. §1395 ET SEQ. (1970 ED.
AND SUPP. III 1972), AS AMENDED FROM TIME TO TIME, AND
"SUBCHAPTER XIX. - GRANTS TO STATES FOR MEDICAL
ASSISTANCE PROGRAMS" (MEDICAID) 42 U.S.C. §1396 ET SEQ.
(1970 ED. AND SUPP. III 1972), AS AMENDED FROM TIME TO
TIME, THE PROFESSIONAL STANDARDS REVIEW ORGANIZATION,
CONSISTENT WITH THE CERTIFICATION OF THE SECRETARY OF THE
UNITED STATES DEPARTMENT OF HEALTH, EDUCATION AND
WELFARE, IS AUTHORIZED TO REVIEW HEALTH AND MEDICAL
SERVICES OF THE HEALTH MAINTENANCE ORGANIZATIONS;

(8)    WITH THE APPROVAL OF THE DEPARTMENT OF
HEALTH AND MENTAL HYGIENE, THE ORGANIZATION HAS PROVIDED
FOR AN INTERNAL PEER REVIEW WHICH WILL PROVIDE FOR
CONTINUOUS MONITORING AND EVALUATION OF PATIENT RECORDS
FOR QUALITY OF CARE AND FOR OVER-UTILIZATION AND
UNDER-UTILIZATION OF PROVIDER CARE;

(9)      THE ORGANIZATION HAS PROVIDED AN
INTERNAL GRIEVANCE SYSTEM TO RESOLVE ADEQUATELY ANY
GRIEVANCES INITIATED BY ANY OF ITS MEMBERS, IN A MANNER
APPROVED BY THE DEPARTMENT OF HEALTH AND MENTAL HYGIENE
ON MATTERS CONCERNING QUALITY OF CARE AND BY THE
COMMISSIONER ON FINANCIAL MATTERS, IN ACCORDANCE WITH
JOINT INTERNAL ADMINISTRATIVE RULES AND PROCEDURES;

(10)    PROCEDURES ARE ESTABLISHED TO OFFER ALL
MEMBERS [[OR PUBLIC REPRESENTATIVES]] AN OPPORTUNITY TO